Some upheld, recommendations

Summary

Mr and Mrs C attended the Aberdeen Fertility Centre and were diagnosed with unexplained infertility. They underwent two in vitro fertilisation (IVF) cycles but neither cycle resulted in pregnancy. The board decided not to offer a further IVF cycle, saying that egg donation could be considered. Mr and Mrs C underwent assisted conception treatment privately. This found that Mrs C's ovarian reserve (the capacity of a woman's ovaries to produce healthy eggs) was higher than expected, and that Mr C's sperm had a significant number of antibodies which caused the sperm to stick together. Mrs C raised concerns about aspects of the assisted conception care and treatment provided by the Aberdeen Fertility Centre as well as the nursing care provided. She also raised concerns about the way the board handled their complaint.

We found that the board's actions were reasonable in relation to the provision of assisted conception. However, in light of the new information about the nature of the couple's infertility and Mrs C's ovarian reserve, we recommended that the board consider whether the couple met the board's eligibility criteria (as outlined in their policy) for a third round of IVF treatment. We also found communication and record-keeping failures by nursing staff, particularly around pain assessment and relief. In relation to the board's complaints handling, we found that the board should have told Mrs C about the delays in responding to her complaint, the reasons for the delays, and of her right to approach us in such circumstances.

Recommendations

We recommended that the board:

• consider whether Mr and Mrs C meet the eligibility criteria in the board's policy for a third cycle of assisted conception treatment in light of the new information about the nature of their infertility and Mrs C's ovarian reserve;
• bring the record-keeping and communication failures to the attention of relevant staff and review the process to ensure there is no recurrence;
• apologise for the failures identified in complaints handling and bring them to the attention of relevant staff; and
• apologise for the failures identified.

Summary

Mr A, who had a history of type 1 diabetes, chronic kidney disease and who had had a leg amputated, was admitted to Dumfries and Galloway Royal Infirmary in November 2013. He was complaining of chest pain, a shortage of breath and had an ulcerated toe. After admission, Mr A continued to be unwell and a week later, he had a cardiac arrest and died. His sister (Mrs C) complained that board staff failed to do enough for him or to recognise that he was a very sick patient. She also complained about the way in which her formal complaint was subsequently handled.

We took independent advice from a consultant geriatrician with an accreditation in general medicine and from a senior nurse. We found that Mr A's condition was a complex one and that doctors had treated him reasonably in terms of his symptoms and there were no reasonable precautions that could have been taken which could have prevented his death with certainty. We also found that the nursing care given to Mr A had been reasonable, although we identified some failure and shortcomings in record-keeping. We did not uphold Mrs C's complaints about care and treatment. However, we found that Mrs C's complaint had been dealt with badly. It did not initially progress through the complaints process and was beset by delay and confusion. Even when the board identified that this had happened, Mrs C was sent an inadequate reply. For these reasons, we upheld this part of the complaint.

Recommendations

We recommended that the board:

• remind the nursing staff involved in Mr A's care of their responsibility to keep appropriately detailed records;
• make a full apology for the delay and confusion in dealing with Mrs C's complaint; and
• ensure that they provide complaint responses that are thorough and appropriate.

Summary

Ms C raised a number of concerns about the care and treatment her father (Mr A) received at Biggart Hospital. Mr A had been transferred from another hospital for rehabilitation after he suffered a fracture to his right upper arm after a fall.

We took independent advice on the case from a medical adviser and a nursing adviser.

The medical adviser considered that while communication between ward staff and the fracture clinic fell below a reasonable level, the board had acknowledged this and apologised. The medical adviser said the length of Mr A's stay at the hospital was reasonable, based on the injury he had suffered and his particular circumstances. The medical adviser considered the initial assessment of Mr A's chest fell below a reasonable standard because, although in their complaints response the board stated that this was to treat a chest infection, Mr A's medical records did not record why he was prescribed antibiotics and how this treatment would be reviewed.

The medical adviser and the nursing adviser both considered that further investigation and assessment should have been made when swelling to Mr A's leg was identified by nursing staff.

The advisers also said that Mr A had not been provided with a reasonable amount of physiotherapy treatment and there was a lack of provision of physiotherapy for Mr A on weekends and bank holidays. They also considered the amount of occupational therapy provided to Mr A was below a reasonable level. Although the board had apologised to Ms C that the level of support fell short of her expectations, the medical adviser was critical of the board's failure to acknowledge that a lack of staff time and workload commitments had impacted on the service Mr A received.

Recommendations

We recommended that the board:

• feed back the findings about Mr A's swollen leg to the staff involved, for reflection and learning, including reminding nurse practitioners to highlight abnormal clinical findings to medical staff;
• feed back the failures in relation to record-keeping to the staff involved, for reflection and learning;
• provide evidence of the review of physiotherapy staffing levels and provision of their services;
• consider and report on steps taken to address the failings in provision of occupational therapy identified by this investigation; and
• issue a general written apology to Ms C, acknowledging the failings identified in this investigation.

Summary

Ms C owned a property in Edinburgh. In 2007 the council issued a statutory notice requiring repairs to a rooftop drying green shared by several properties. The property owners did not appoint a contractor of their own and the council took over responsibility for the works. The owners were provided with an initial estimate of the cost of the works. However, once the work had started, this escalated substantially. Ms C raised a number of concerns about the lack of information as to why the price had changed so much, the council's failure to explain their minimum charges and additional work carried out at extra cost without consultation with the owners.

We were critical of the council's handling of the sizeable cost increase. Whilst there was no suggestion that the work was unnecessary, we found that they could have provided a more realistic estimate at the beginning of the process to better manage the owners' expectations. We were not concerned by their communication of the minimum charges and were generally satisfied that the additional works were added to the project reasonably. However, we commented on the way that these works were communicated to the owners.

Recommendations

We recommended that the council:

• apologise to Ms C for their poor communication throughout the repairs project;
• consider how they may better research the likely cost of repairs when issuing their initial estimates; and
• pay Ms C the sum of £250 in acknowledgement of the time and trouble she had to go to to obtain clarification of the works being carried out and their associated costs.

Summary

As Mrs C lived within a two-mile radius of her child's secondary school, her child was not entitled to free transport to school. Although she accepted this, she considered that the route her child had to walk was not safe because of the lack of lighting, the low priority the path had for gritting in the winter, and the volume of traffic on a fast road. She said that the council had not paid appropriate heed to guidance from the Scottish Government. When she complained to the council about the assessment of the walking route, she did not consider their response adequately addressed her complaints and the issues she raised.

We found that the council had applied an assessment methodology which was developed around English legislation, which did not consider street lighting to be significant. We also reviewed the Scottish Government guidance on this issue, and found that it allowed for significant flexibility in how councils consider various aspects of road safety. We therefore considered that it was reasonable for the council to use the assessment methodology as they did, and this was in line with the exercising of their professional judgement, and so we did not uphold this complaint. We also noted that neither set of guidance mentioned the need to take account of gritting of pavements in winter weather. However, we noted the lack of any internal policy at the time of the assessment in question. The council assured us they had since adopted a policy, but did not provide a copy.

In relation to complaints handling, we found that the council had not provided clear responses to the concerns which Mrs C raised. We therefore upheld this complaint. We also noted that the officer who investigated the complaint was the same one involved in earlier correspondence on this issue, which raised concerns about the independence of their investigation.

Recommendations

We recommended that the council:

• feed back the findings of this complaint to the relevant complaints handling staff; and
• apologise to Mrs C for not responding to her complaints in line with their complaints handling procedure.

Summary

Mr C complained about the council's handling of matters relating to his granddaughter (Miss A). His son (Mr A) had lost custody of his daughter (Miss A) following separation from his wife (Ms D). Whilst pursuing access to Miss A through the social work department, Mr A and Mr C raised a number of concerns about how their complaints were handled, the accuracy of information in reports, and allegations made about Mr A which they did not consider to be accurate. They also complained that Mr A's application for housing was not handled fairly.

We were satisfied that Mr C and Mr A's complaints were handled appropriately through the social work complaints procedure. Those issues that could not be considered were directed towards other more suitable organisations. We were also satisfied that Mr A's housing application was fairly handled.

We found that the council consistently acted with Miss A's interests in mind and found nothing that would question the validity of decisions made regarding her welfare. That said, we were critical of the council for failing to clearly explain the role of a person appointed to support Ms D, and for failing to properly document their consideration of counter-allegations that Mr A had made against Ms D.

Recommendations

We recommended that the council:

• review the way that they explain the role of support workers and the level of involvement that they could have in such cases;
• apologise to Mr A for the issues highlighted in our decision; and
• review the extent to which the support worker may have been providing a service to Miss A as well as Ms D and provide details on the outcome of their review to Mr A.

Summary

Mrs C complained about how the council dealt with bullying at her child's school. Mrs C said that the head teacher had shown a lack of care towards her child, that their ineffective action led to the continued bullying of her child and that the anti-bullying policy was not well advertised. The council did not uphold her complaints about the school's lack of care or advertising of the policy, although they partially upheld the complaint that ineffective action led to continued bullying.

We considered two complaints from Mrs C. These were that reported bullying incidents were not dealt with effectively and that effective measures were not taken to protect her child in line with the anti-bullying policy. We found that the school had taken appropriate steps to investigate the reported bullying incidents and that this action was in line with their anti-bullying policy. There was no evidence that there had been a lack of care in this regard and we did not uphold this aspect of Mrs C's complaint. We upheld Mrs C's second complaint regarding the effectiveness of action taken as we found that the council had identified failings and that there were some issues with how reported bullying incidents had been recorded. There was no evidence that the anti-bullying policy was not advertised, but we did consider that it may have been beneficial to have drawn it to the attention of Mrs C when she first reported the bullying of her child.

Recommendations

We recommended that the council:

• issue Mrs C with a written apology for the issues identified during their investigation of the effectiveness of action taken by the school;
• update us on the outcome of the recommendations made to the school following the council's investigation and how these have addressed the issues identified;
• consider the potential benefits of drawing the school's policy to the attention of parents reporting bullying incidents; and
• review how the available electronic resources are used to record and track bullying incidents, including those reported by parents or some time after the event itself.

Summary

Mrs C gave notice to the housing association to terminate her tenancy. An end of tenancy letter was issued by the association detailing her responsibilities prior to moving. A pre-end of tenancy inspection was carried out. The association issued Mrs C with a further letter advising that no rechargeable repairs had been identified. The letter did, however, make it clear that rechargeable repairs could be found on further inspection after she had moved out. Mrs C was subsequently recharged for a redecoration allowance, plaster repairs and emptying wheelie bins at the property. Mrs C complained that the recharges should not have applied, and that she understood from her tenants' handbook that estimates should have been issued before any work took place.

After investigating Mrs C's concerns, we did not uphold her complaint about the redecoration allowance. We found it was clear that the property was to be left in good decorative order and that the association had evidence to support their position on its condition. Similarly, we considered that the association had taken reasonable steps to make Mrs C aware that she would be liable for any damage, such as that caused to plasterwork. Again, the association had evidence to support their position on the condition of the plasterwork. We upheld Mrs C's complaint about recharges for the emptying of wheelie bins as we found no evidence that it had been made clear that outgoing tenants were unable to leave rubbish in the wheelie bins. During our investigation, the association advised that it is not their policy to issue estimates prior to recharging for works in these circumstances. However, they acknowledged that their tenants' handbook did imply that this would happen. Consequently, we upheld Mrs C's complaint about estimates. We also upheld her complaint on the association's handling of her concerns as we found some issues had not been addressed. We made a number of recommendations in relation to our findings. One of these related to clarifying the wording of compensation offers, as we found an offer made to Mrs C was not clear in its scope.

Recommendations

We recommended that the association:

• remove the charge for emptying wheelie bins from Mrs C's account;
• review all relevant policies and guidance to determine if any amendments are required to clarify tenants' responsibilities in terms of emptying wheelie bins at termination;
• review the tenants' handbook and other information provided to tenants to ensure it accurately reflects their policy on estimates;
• issue Mrs C with a written apology for the failure to address all her concerns in their response to her complaint; and
• consider reviewing how compensation offers are worded so that the scope and intention is clear to tenants.

Summary

Mr C complained about an ambulance crew that attended his wife (Mrs C). After Mrs C was taken to hospital, she was diagnosed with a ruptured abdominal aortic aneurysm (a weak point in a blood vessel), which was a life-threatening condition. Mr C said the crew did not diagnose his wife's condition or provide treatment for it, and did not regard the situation as an emergency. In addition, Mr C was unhappy with the ambulance service's response to his complaint.

We took independent advice from an adviser who is a consultant in emergency medicine. Although we would not expect the crew to make a definitive diagnosis of an abdominal aneurysm, we found that they should be able to recognise when a patient is seriously unwell. In this case, the crew assumed that Mrs C's symptoms were due to sciatica (back and leg pain caused by irritation or compression of the sciatic nerve) or muscular back pain, and they failed to recognise that she had a life-threatening condition. We upheld this part of Mr C's complaint. Once the crew decided to take Mrs C to hospital they gave her morphine. In this respect, they provided treatment to Mrs C and so we did not uphold this part of Mr C's complaint.

The crew did not use blue lights when taking Mrs C to hospital, which was reasonable as it was the early hours of the morning. However, doing this was another indication that the crew did not recognise Mrs C was seriously unwell, as was their discussion about leaving Mrs C at home for review by her local doctor. We upheld Mr C's complaint that the crew failed to regard the situation as an emergency. In addition, we had concerns about the accuracy of the ambulance service's response to Mr C, and we upheld this aspect of his complaint.

Recommendations

We recommended that the ambulance service:

• apologise to Mr C for the failings identified by our investigation;
• ensure that staff are aware of the signs and symptoms of leaking abdominal aortic aneurysms, including atypical presentations;
• ensure that staff are aware that normal vital signs do not exclude serious and life-threatening medical and surgical conditions;
• ensure that, when making a decision not to transport patients to hospital, their staff document detailed history and examination findings which confirm the diagnosis of a minor illness. Documentation in these circumstances should demonstrate that significant clinical findings, both positive and negative, have been interpreted within the context of the clinical history and inform the clinical outcome;
• ensure that, when making a decision not to transport a patient to hospital, their staff reference which alternative pathway route is being followed; and
• ensure that staff investigating complaints use appropriate reference material, such as clinical textbooks, when considering matters of clinical judgement.

Summary

Mr C complained on behalf of his daughter (Ms C) about the treatment that her mother (Mrs A) received at the Royal Infirmary of Edinburgh. Mrs A was admitted to A&E suffering with back pain, vomiting and palpitations. It was considered that she may have had a kidney infection with systematic septic response (a potentially life-threatening condition triggered by an infection). Mrs A was treated with antibiotics and fluids before being admitted to the acute medical unit where she was assessed. It was then decided to withhold the antibiotics until the source of the infection had been identified. Mrs A was admitted to a ward the following morning and test results showed that she was suffering from a urinary tract infection which was then treated. Mrs A's condition deteriorated and she had to be admitted to intensive care. As Mrs A's liver was failing, a transplant was organised. However, she remained very ill following this and later developed a perforation in her bowel. Mrs A died in hospital as a result of her illness.

Mr C asked us to investigate his concerns about Mrs A's treatment, particularly the prescription of antibiotics during the initial stages. Mr C was also concerned about record-keeping and communication with the family during Mrs A's time in hospital. After taking independent advice on this case from a consultant in general medicine, we upheld Mr C's complaint about medical treatment. We found that there had been a delay in the initial administration of antibiotics in the A&E department. Our adviser said that it would have been reasonable to continue to treat Mrs A with antibiotics while awaiting test results to determine the source of the infection. Our adviser found that the board had not followed their sepsis protocol as, in addition to the issues around administration of antibiotics, blood cultures were not taken until two days after Mrs A's admission to the hospital. We found that other aspects of Mrs A's treatment were reasonable. We did not uphold the second part of Mr C's complaint as we found no evidence that the communication with family members was unreasonable.

Recommendations

We recommended that the board:

• apologise to Mr C and Ms C for the failures identified in the initial management of Mrs A's condition;
• ensure that this case is included for discussion at the next appraisals of the doctors who made the antibiotic prescription decisions; and
• ensure that staff at the acute medical unit are reminded of the need to maintain accurate contemporary records.